Plan for today NVMT /4/2018. But what about TSM for thoracic spine pain? The Thoracic Spine as a Special Region:

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1 The Thoracic Spine as a Special Region: Evidence for effectiveness Risks associated with manipulating the thoracic spine & Pain Neuroscience Education Plan for today 1. Evidence for the effectiveness of thoracic spine manipulation 2. Prevalence of the use of thoracic spine manipulation 3. Risks associated with manipulating the thoracic spine 4. Pain Neuroscience Education Emilio Louie Puentedura, PT, DPT, PhD Bizzarri, P et al. Thoracic manual therapy is not more effective than placebo thoracic manual therapy in patients with shoulder dysfunctions: A systematic review with meta analysis. Musculoskelet Sci Pract Feb;33:1 10. Hidalgo, B et al. The efficacy of manual therapy and exercise for treating non specific neck pain: A systematic review. J Back Musculoskelet Rehabil Nov 6;30(6): Minkalis, AL et al. A systematic review of thrust manipulation for non surgical shoulder conditions. Chiropr Man Therap Jan 4;25:1 Peek, AL et al. Thoracic manual therapy in the management of non specific shoulder pain: a systematic review. J Man Manip Ther Sep;23(4): Salom Moreno, J et al. Immediate changes in neck pain intensity and widespread pressure pain sensitivity in patients with bilateral chronic mechanical neck pain: a randomized controlled trial of thoracic thrust manipulation vs non thrust mobilization. J Manipulative Physiol Ther Jun;37(5): Southerst, D et al. The effectiveness of noninvasive interventions for musculoskeletal thoracic spine and chest wall pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. J Manipulative Physiol Ther Sep;38(7): Chu, J et al. Peripheral response to cervical or thoracic spinal manual therapy: an evidence based review with meta analysis. J Man Manip Ther Nov;22(4): Young, JL et al. Thoracic manipulation versus mobilization in patients with mechanical neck pain: a systematic review. J Man Manip Ther Aug;22(3): Huisman, PA et al. The effect of thoracic spine manipulation on pain and disability in patients with non specific neck pain: a systematic review. Disabil Rehabil Sep;35(20): Vincent, K et al. Systematic review of manual therapies for nonspecific neck pain. Joint Bone Spine Oct;80(5): Cross, KM et al. Thoracic spine thrust manipulation improves pain, range of motion, and self reported function in patients with mechanical neck pain: a systematic review. J Orthop Sports Phys Ther Sep;41(9): Engel, R et al. The role of spinal manipulation, soft tissue therapy, and exercise in chronic obstructive pulmonary disease: a review of the literature and proposal of an anatomical explanation. J Altern Complement Med Sep;17(9): Walser, RF et al. The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: a systematic review and meta analysis of randomized clinical trials. J Man Manip Ther. 2009;17(4): Mintken, PE et al. Some factors predict successful short term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single arm trial. Phys Ther Jan;90(1): RCTs included 7 were of high quality (PEDro) 3 studies on treatment of shoulder conditions little evidence to support 9 studies on treatment of neck conditions sufficient evidence to support Pooled estimator (1.33) statistically significant for treatment effect of TSM with researcher effect removed (95% CI: ) There is sufficient evidence to support the use of TSM for specific subgroups of patients with neck conditions But what about TSM for thoracic spine pain? (2017) Online ahead of print: It matters whether clinicians do what they want in research versus do that they re told 13 studies 1313 participants in systematic review 12 studies 977 participants in the meta analysis Results: When pragmatic design used (actual clinical practice) patients improved no difference between mobilization and manipulation When prescriptive design used (not true clinical practice) patients improved manipulation showed better outcomes than mobilization for pain and disability Does this mean we don t do it right in actual clinical practice? Do we need to change clinical practice to obtain the true benefits of spinal manipulation? 1

2 Limited research of the thoracic spine, Cinderella region Thoracic dysfunction is under explored Thoracic spine manipulation is beneficial for managing neck and shoulder pain Thoracic spine may be viewed as a silent contributor to clinical presentations Further research of thoracic spine pain and dysfunction is needed Questions TJM to the C spine not taught to same degree as other regions of spine in first degree PT programs PTs tend to use it less frequently in clinical practice How is TJM to the spine viewed by US PTs? 1. Utilization of TJM within the 3 spinal regions 2. Thoughts about safety and efficacy of TJM in each spinal region 3. Perceived barriers to utilization of TJM by US PTs Group (n = 1000) Males (n = 478) Females (n = 519) P value Age (mean ± SD) 39.8 ± ± ± Years of practice (mean ± SD) 13.5 ± ± ± Entry level Degree DPT MPT/ MSPT BPT/ BSPT Certificate/ Other Highest earned Degree PhD/ DSc/ EdD DPT MPT/ MSPT BPT/ BSPT Manual Therapy/ Clinical Specialty Certification 42.9% 31.2% 23.0% 2.9% 4.1% 59.7% 19.9% 11.7% 47.9% 55.8% 39.0% 37.9% 70.7% 50.5% 48.7% 31.0% 52.1% 44.2% 61.0% 62.1% 29.3% 49.5% 51.3% 69.0%.003*.000* 48% 57.7% 42.3%.000* Safe and Effective Perform additional screening before TJM Wilcoxon Signed Ranks Test revealed significant differences between thoracic and lumbar spines (p=.001); between thoracic and cervical spines (p=.000); and between lumbar and cervical spines (p=.000). 2

3 Regularly provide TJM Comfortable performing TJM Manipulative practice in the thoracic spine: a survey of current practice of Physiotherapists in the UK Sally Davies, Emilio Puentedura, Nicola Heneghan Survey of 276 physios in the UK (53% males) mean age 36 (8.7) yrs means years in practice 11 (8.1) Only 40% use any additional screening before using TJM to the Thoracic Spine Preferred choice was prone manipulation (67%) Most consider underlying effect of TJM to be: neurophysiological (54%) biomechanical (45%), and placebo (1%) Very high levels of agreement for stated contraindications (85%); precautions (75%); red flags (86%) and risks (61%) Submitted for publication Is it that much safer in the T spine? Remember, US physical therapists feel most comfortable, regularly perform, and believe thrust joint manipulation is safest in the Thoracic Spine Do serious adverse events occur in the Thoracic Spine? chiropractic work.php 10 cases reported in 7 case reports Females (8) more involved than males (2) Mean age 43.5 years (SD = 18.73, Range = 17 71) Adverse Events reported: Injury (mechanical or vascular) to spinal cord (7/10) Pneumothorax/ hematothorax (2/10) CSF leak after dural sleeve injury (1/10) myelitis 2 3

4 Conclusions: Serious AE do occur in the thoracic spine, most commonly, trauma to the spinal cord, followed by pneumothorax Suggests that excessive peak forces may have been applied to thoracic spine, and should serve as a cautionary note for clinicians to decrease these peak forces. What is Pain Neuroscience Education? Teaching patients how pain really works from a physiological and neurophysiological perspective My pain is due to the bulging disc I hurt because I have arthritis Movement will damage tissue and increase pain Pain means something is wrong I am not doing anything until all pain is gone I am afraid my pain will get worse I have a very rare case of If persistent pain and disability are due to faulty cognitions Would this hurt? What if? Moseley, G.L., A pain neuromatrix approach to patients with chronic pain. Man Ther, (3): p Moseley GL. Reconceptualising pain acording to modern pain sciences. Physical Therapy Reviews. 2007;12: How Dangerous is this? This is not dangerous Inhibition Endogenous How Dangerous is this? This is dangerous More information Facilitation Neuronal adaption Pain is a decision by the brain based on perception of THREAT The dichotomy Nijs J, Roussel N, Paul van Wilgen C, Koke A, Smeets R. Thinking beyond muscles and joints: therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther. Apr 2013;18(2): Pain is produced by the brain Altering information the brain receives can potentially alter threat and thus the pain experience Bottom Up Top Down Louw A. Treating the brain in chronic pain. In: C FdlP, J C, Dommerholt J, eds. Manual Therapy for Musculoskeletal Pain Syndromes. Vol 1. London: Churchill Livingston;

5 What makes the T Spine such a special region for manual therapy? Plastic brain maps Relatively stiff (hypomobile) region compared to C and L spines 6 synovial joints per vertebral level CV, CT & ZPJ compared to just 2 per level ZPJ in C and L spines Presence of sympathetic chain anterolaterally Relatively narrower vertebral canal for spinal cord and dura Abundance of segmental muscles (rotatores, levatores costarum) with perhaps proprioceptive vs movement function Protective function lungs and heart Life sustaining function breathing Biologically coded Environmentally sculpted Changes occur in minutes Summary 24 patients with mechanical neck pain Randomized to receive Thrust Manipulation or Sham to T spine fmri scanning while receiving noxious stimuli pre and postintervention Significant group differences Thrust group increased areas of activation in insular and somatosensory cortices Sham group greater activation of precentral gyrus, supplementary motor area, and cingulate cortices Thrust Joint Manipulation to the Thoracic Spine is helpful in a subset of patients with musculoskeletal dysfunction (neck > shoulder) Thoracic dysfunction is under explored and its management with Thrust Joint Manipulation is not well researched Physiotherapists in the US appear to be more comfortable manipulating the thoracic spine than other regions of the spine and may not fully appreciate the risks Adverse events following Thrust Joint Manipulation to the thoracic spine do occur and it is recommended that clinicians use sound clinical reasoning and work to develop their skills in manipulation to minimize force The Thoracic Spine may be considered a special region from a Pain Neuroscience point of view as it is richly innervated (bottom up mediation) and restoring/ improving motion may induce favorable neuroplastic changes 5